The health-related quality of life of overweight and obese adolescents - a study measuring body mass index and adolescent-reported perceptions

Objective. To determine whether the health-related quality of life (HRQOL) of overweight and obese adolescents is significantly lower than that of their healthy weight counterparts, and if so, whether any demographic trends exist and the relative contribution of each HRQOL dimension.

Methods. Cross-sectional analysis of 2,890 students participating in the Pacific Obesity Prevention in Communities Project, Australia. HRQOL was measured using the Pediatric Quality of Life Inventory (PedsQL) adolescent module. Adolescent height and weight were measured by trained field workers and weight categories assigned according to the International Obesity Task Force BMI cut-off points for adolescents. Multivariate linear regression analyses were undertaken to estimate the mean differences in HRQOL scores between (i) overweight and healthy weight, and (ii) obese and healthy weight adolescents, whilst adjusting for gender, age and socioeconomic status quartile.

Results. The sample had a mean age of 14.6 years (range 11–18), 56.2% boys, 20.2% overweight and 6.3% obese. Higher weight status categories were associated with lower HRQOL scores (mean PedsQL scores: healthy weight: 79.1, overweight: 77.7 and obese: 73.7). Relative to the healthy weight group, and after adjustments, overweight and obese adolescents reported 1.44 (p = 0.005) and 5.55 (p < 0.001) lower HRQOL summary scores, respectively. Overweight adolescents reported significantly lower scores in physical and social functioning, whilst obese adolescents reported significantly lower scores in the same dimensions plus emotional functioning. Girls and younger (< 15 years) adolescents reported greater mean negative HRQOL differences associated with excess weight.

Conclusions. Overweight and obesity in adolescents are associated with significantly lower HRQOL scores.

Utility-based quality of life of overweight and obese adolescents

Objective : To explore the relationship between overweight/obesity and utility in adolescents.

Methods : Data were collected from 2890 adolescents attending 13 secondary schools in the state of Victoria, Australia. The Assessment of Quality of Life 6-Dimension (AQoL-6D) questionnaire was used to measure individual utility. Adolescent's height and weight were measured and weight status categories assigned according to the World Health Organization adolescent growth standards. Multivariate linear regression analyses were undertaken for the whole population and subpopulations of boys and girls to estimate the mean differences in utility scores between 1) overweight and healthy weight and 2) obese and healthy weight adolescents, while controlling for demographic and socioeconomic status variables.

Results : The mean age of adolescents was 14.6 years, 56.2% were boys, 22.2% were overweight, and 9.4% were obese. The mean utility of healthy weight adolescents was 0.860. After adjustments, the overweight and obese groups reported significantly lower mean utility scores (differences: −0.018 and −0.059, respectively, relative to the healthy weight group). This can be interpreted as equivalent to a stated willingness to sacrifice 1.8% and 5.9% of a life in perfect health or 2.3% and 6.8% of a life at healthy weight. A significant utility difference associated with overweight was only experienced by girls (−0.039, P = 0.003). Both sexes experienced significant utility differences associated with obesity, but the magnitude was double for girls (−0.084, P < 0.001) relative to boys (−0.041, P = 0.022).

Conclusion : Utility is lower among overweight and more so among obese adolescents.

Treatment acceptability and psychosocial outcomes of a randomised controlled trial of a cognitive behavioural lifestyle intervention for overweight and obese adolescents

This study explores the impact of a cognitive behavioural lifestyle program, the CHOOSE HEALTH Program, on psychosocial wellbeing in overweight and obese adolescents. The sample comprised 29 male and 34 female adolescents aged 11.5 to 18.9 years (M = 14.3, SD = 1.9) and classified as overweight (n = 15) or obese (n=48). Participantswere randomly allocated to treatment or wait-list control conditions; participants allocated the wait-list condition were offered treatment after 6 months. Adolescents and parents completed self-report measures of psychopathology, psychosocial and family functioning. Treatment did not have detrimental effects on the psychosocial factors assessed. It resulted in significant improvements in weight control behaviour, impulse regulation, social support from family and parent–adolescent problem communication (p<.05). Similar results were obtained with completer and intention-to-treat analyses. Treatment acceptability was high, with all respondents indicating that they made progress. Combined, results indicate that treatment did not have detrimental effects on psychopathology, psychosocial functioning, or family functioning. Treatment resulted in significant improvements in impulse regulation, social support from family and parent–adolescent communication. Thus, parents and professionals can be assured that a comprehensive, multifaceted, parent-supported, cognitive behavioural intervention for overweight and obese adolescents does not cause psychological harm.

A cognitive behavioural intervention for overweight and obese adolescents illustrated by four case studies

This article reports four case studies illustrating the implementation of the CHOOSE HEALTH Program, a cognitive behavioural lifestyle intervention for overweight and obese adolescents. Participants were an overweight (12 years) and obese (15 years) female, and an overweight (14 years) and obese (12 years) male. The program was delivered by provisional psychologists with program specific training and supervision. All participants demonstrated improvements in body composition, and maintained or improved dietary quality and psychosocial wellbeing. The program had variable effects on physical activity and minimal effect on cardiovascular fitness for three of the four participants. While parents and adolescents required considerable assistance to develop and monitor long term program goals, these goals were a useful clinical tool to support the adolescent and parent to recognise the improvements they had made. Identification and monitoring of specific, measurable, and realistic behaviour change strategies was particularly important in assisting adolescents and their parents to translate session information into improved health behaviours. Results indicate that an adolescent overweight and obesity treatment program that promotes adolescent responsibility and autonomy, and emphasises the importance of parent support and family change is both effective and highly acceptable to both adolescents and parents.

Psychosocial predictors of eating disorder risk in overweight and obese treatment-seeking adolescents

This study explored eating disorder risk factors and possible psychosocial predictors of this risk in overweight and obese treatment-seeking adolescents. Prior to commencing treatment 108 overweight and obese adolescents aged 11 to 17 years (M = 14.31, SD = 1.57; 55% female) completed self-report measures of psychosocial factors. Females reported elevated levels of bulimic tendencies, body dissatisfaction, drive for thinness (p ≤ .001) and males reported elevated body dissatisfaction (p < .001). Age, sex and BMI-for-age z-score explained 15% (p < .001) of the variance in eating disorder risk and psychosocial predictors an additional 25%. Sex did not have a moderating effect on these relationships (p = .21). Among overweight and obese treatment-seeking adolescents, those experiencing lower self-esteem and elevated depression and anxiety symptomatology are at increased eating disorder risk. This highlights the need to consider psychosocial factors in preventing and treating overweight and obesity.

Understanding the correlates of adolescents' TV viewing : a social ecological approach

Objective. To examine associations between social ecological factors and Dutch adolescents’ TV viewing. Design. Cross-sectional examination of predictors of adolescents’ TV viewing.

Participants. A total of 338 adolescents, aged 14 years (55% boys).

Measurements. Adolescents self-reported their age, ethnicity and TV viewing (dichotomized at two hours/day) and responded to items from all three social ecological domains; individual (cognitions based on the Theory of Planned Behaviour and TV viewing habit strength, and other behaviours, such as computer use), social (parental rules about TV viewing and parental TV viewing behavior) and physical environmental factors (TV in bedroom, physical activity equipment available). Parents reported demographic factors (e.g., ethnicity, education level), and their own TV viewing (mins/day); adolescents’ weight status (not overweight vs. overweight/obese) was calculated from objective measures of height and weight. Logistic regression analyses examined associations between socio-ecological factors and adolescents’ TV viewing, and whether associations were moderated by adolescents’ sex, parents’ education and ethnicity.

Results. Compared with others, overweight/obese adolescents (odds ratio (OR)=3.0; p≤0.001), those with high computer use (OR=2.3; p≤0.0001), with high TV viewing habit strength (OR=1.3; p≤0.0001), and those whose parents had high levels of TV viewing (OR=2.4; p≤0.01) were more likely to exceed two hours of TV viewing per day. The association with habit strength was moderated by gender, and the association with parents’ TV viewing was moderated by parents’ education and ethnicity.

Conclusions. Interventions should target parents’ TV viewing behaviors and aim to amend habitual, ‘mindless’ TV viewing among adolescents.

Self-monitoring in the treatment of overweight adolescents

The aim of this study was to explore the relationship between the quantity and quality of self-monitoring and per cent fat loss in overweight and obese adolescents participating in a weight-loss intervention. Participants were 55 (33F) overweight and obese adolescents taking part in a 20-week cognitive–behavioural intervention aimed at improving eating and physical activity behaviours. Food and physical activity self-monitoring from the first 9 weeks of the intervention was coded using 24 components assessing the quantity (20) and quality (4) of selfmonitoring. Those who completed treatment (n = 42) were split into groups: Losers (n = 30) and Gainers (n = 12) of per cent body fat as measured by DXA. Group analyses showed that Losers and Gainers could be differentiated by both quantitative and qualitative measures of self-monitoring. The strongest associations were with the classifications of food and drink items into food groups. The number of days monitored and the average number of items recorded did not differentiate the groups. Quantity and quality measures of self-monitoring completed early in treatment could also differentiate those who completed treatment and those who did not complete treatment (n = 13), and the strongest associations were with the amounts of food and drink items recorded, an association not found with treatment outcome. The results indicate that both quantity and quality of self-monitoring may be important predictors of both treatment completion and outcome. Based on these findings a framework of self-monitoring requirements is offered to reduce homework burden while maximising treatment efficacy.

Weight perception in overweight adolescents: Associations with body change intentions, diet and physical activity

This study examined the association of weight perception and weight satisfaction with body change intentions and weight-related behaviours in 928 overweight adolescents (aged 11-18 years, 44% female). Accurate perception of weight was associated with trying to lose weight and inaccurate perception was associated with trying to gain muscle. Weight dissatisfaction was associated with trying to lose weight and gain muscle. Accurate weight perception and weight dissatisfaction were not associated with healthy weight-related behaviours. Awareness of overweight and body dissatisfaction may be detrimental to the adoption of healthy weight-control behaviours. Interventions with overweight adolescents should encourage body satisfaction, rather than promoting awareness of overweight.

Comorbidites of overweight/obesity experienced in adolescence : longitudinal study

Objectives: Adolescent obesity is linked to measurable, asymptomatic metabolic and cardiovascular precursors, but its associations with adolescents’ experienced health and morbidity is less clear. The objective of this paper was to determine (1) Prevalence of comorbidities experienced by overweight/obese adolescents; (2) Associations between timing of overweight/obesity and morbidity.

Methods: Data were drawn from the three waves (1997, 2000, 2005) of the Health of Young Victorians Study (HOYVS), an Australian school-based longitudinal study. The main outcome measures were blood pressure; self- and parent-proxy reported health status (PedsQL, global health); self-reported mental health (SDQ), psychological distress (K-10), physical symptoms, sleep, asthma, and dieting; parent-reported health care needs (CSHCN screener) and visits. Regression methods, adjusted for sociodemographic factors, were used to assess associations with (1) Body mass index (BMI) status (non-overweight, overweight or obese) and (2) Timing of overweight/obesity ( never , childhood only , adolescence only , ‘persistent ).

Results: Of the 923 adolescents (20.2% overweight, 6.1% obese), 63.5% were categorised as ‘never’ overweight/obese, 8.5% as ‘childhood only’, 7.3% as ‘adolescence only’, and 20.8% as ‘persistent’. Current BMI status was strongly associated with poorer physical and global health, hypertension and dieting behaviours. Associations were weaker for emotional morbidity, and there was no clear evidence of association with any other variable. Other than dieting, adolescent morbidity was not associated with resolved childhood overweight/obesity.

Conclusions: Despite poorer overall health, overweight/obese adolescents were not more likely to report specific problems that might prompt health intervention. Morbidity was mainly associated with concurrent, rather than earlier, overweight/obesity.

Assessing cost-effectiveness in obesity (ACE-Obesity) : an overview of the ACE approach, economic methods and cost results

Background : The aim of the ACE-Obesity study was to determine the economic credentials of interventions which aim to prevent unhealthy weight gain in children and adolescents. We have reported elsewhere on the modelled effectiveness of 13 obesity prevention interventions in children. In this paper, we report on the cost results and associated methods together with the innovative approach to priority setting that underpins the ACE-Obesity study.

Methods : The Assessing Cost-Effectiveness (ACE) approach combines technical rigour with 'due process' to facilitate evidence-based policy analysis. Technical rigour was achieved through use of standardised evaluation methods, a research team that assembles best available evidence and extensive uncertainty analysis. Cost estimates were based on pathway analysis, with resource usage estimated for the interventions and their 'current practice' comparator, as well as associated cost offsets. Due process was achieved through involvement of stakeholders, consensus decisions informed by briefing papers and 2nd stage filter analysis that captures broader factors that influence policy judgements in addition to cost-effectiveness results. The 2nd stage filters agreed by stakeholders were 'equity', 'strength of the evidence', 'feasibility of implementation', 'acceptability to stakeholders', 'sustainability' and 'potential for side-effects'.

Results : The intervention costs varied considerably, both in absolute terms (from cost saving [6 interventions] to in excess of AUD50m per annum) and when expressed as a 'cost per child' estimate (from <AUD1.0 [reduction of TV advertising of high fat foods/high sugar drinks] to >AUD31,000 [laparoscopic adjustable gastric banding for morbidly obese adolescents]). High costs per child reflected cost structure, target population and/or under-utilisation.

Conclusions : The use of consistent methods enables valid comparison of potential intervention costs and cost-offsets for each of the interventions. ACE-Obesity informs policy-makers about cost-effectiveness, health impact, affordability and 2nd stage filters for important options for preventing unhealthy weight gain in children. In related articles cost-effectiveness results and second stage filter considerations for each intervention assessed will be presented and analysed.

Motivational interviewing and cognitive behaviour therapy in the treatment of adolescent overweight and obesity : study design and methodology

Background

Despite the high prevalence and negative physical and psychosocial consequences of overweight and obesity in adolescents, very little research has evaluated treatment in this population. Consequently, clinicians working with overweight and obese adolescents have little empirical research on which to base their practise. Cognitive behavioural therapy has demonstrated efficacy in promoting behaviour change in many treatment resistant disorders. Motivational interviewing has been used to increase motivation for change and improve treatment outcomes. In this paper we describe the rationale and design of a randomised controlled trial testing the efficacy of motivational interviewing and cognitive behaviour therapy in the treatment of overweight and obese adolescents.
Methods

Participants took part in a motivational interview or a standard semi-structured assessment interview and were then randomly allocated to a cognitive behavioural intervention or a wait-list control condition. The cognitive behavioural intervention, the CHOOSE HEALTH Program, consisted of 13 individual treatment sessions (12 face-to-face, 1 phone call) followed by 9 maintenance sessions (7 phone calls, 2 face-to-face). Assessments were conducted prior to participation, after the treatment phase and after the maintenance phase of intervention. Improvement in body composition was the primary outcome; secondary outcomes included improved cardiovascular fitness, eating and physical activity habits, family and psychosocial functioning.
Conclusion

Despite the demonstrated effectiveness of motivational interviewing and cognitive behavioural therapy in the long-term management of many treatment resistant disorders, these approaches have been under-utilised in adolescent overweight and obesity treatment. This study provides baseline data and a thorough review of the study design and treatment approach to allow for the assessment of the efficacy of motivational interviewing and cognitive behavioural therapy in the treatment of adolescent overweight and obesity. Data obtained in this study will also provide much needed information about the behavioural and psychosocial factors associated with adolescent overweight and obesity.

The epidemiology of overweight and obesity among Australian children and adolescents, 1995-97

A study attempts to determine the population prevalence of overweight and obesity among Australian children and adolescents, based on measured body mass index (BMI) to determine if overweight and obesity are distributed differentially across the population of young Australians. Data from three independent surveys were analyzed and results indicate that the population prevalence and distribution of overweight, obesity and overweight/obesity combined were 79%-81%, 14%-16%, 5% and 19%-21% (boys) respectively, and 76%-79%, 16%-18%, 5%-6% and 21%-24% (girls). There were no consistent relationships between the prevalence of overweight/obesity and sex, age or SES. It is concluded that some 19%-23% of Australian children and adolescents are either overweight or obese. Only cultural background differential warrant a targeted health promotion response.